Eastern Oklahoma Orthopedic Center Dr. R. Tyler Boone Orthopedic Spinal Surgeon A medical term that refers to fabricating or exaggerating the symptoms of mental or physical disorders for a variety of secondary gain motives. ◦ Intentional, deceptive behavior ◦ Not a medical or psychiatric disorder ◦ Diagnosis rests upon identification of external or “secondary” gain being present as main motivation. Avoidance of going to jail, avoidance of work or family responsibility Desire to obtain narcotics Desire to be awarded money in litigation Need for attention/sympathy Factitious disorder/Munchausen Syndrome by proxy… ◦ Deliberate effort to produce physical or psychological symptoms in order to gain attention ◦ Conscious production of symptoms ◦ Unconscious motivation ◦ Munchausen Syndrome by proxy is creating illness or injury in another Hypochondriasis ◦ Excessive preoccupation with bodily sensation or unrealistic fears of illness Conversion disorder ◦ Unconscious disorder that produces pseudo physiologic symptoms to help resolve personal conflict. Somatization Disorder ◦ Multiple complaints involving various organ symptoms. Partial Malingering Individual has symptoms but exaggerates impact False Imputation upon daily functioning. Individual has valid (“Functional symptoms but is overlay” on an dishonest as to existing disease, source of problems “symptom (injury at home) magnification”). 1. Dramatic or atypical presentation 2. Vague and inconsistent history details 3. History of multiple admissions to various hospitals 4. Substance abuse 5. Presentation to emergency departments at odd times 6. Controlling, hostile, angry, Disruptive, attention-seeking behavior 7. Fluctuating clinical course with rapid development of new symptoms if initial work up negative 8. Symptoms or behaviors only present when patient knows he or she is being observed. 9. Changing doctors when release for work issued. 10. Lack of cooperation and noncompliance with treatment 11. Anti-social or borderline personality. F-scale called malingering index F-K score can distinguish malingerer’s from non-malingerer’s. Table 4. Correlation Between Nonorganic Signs and Minnesota Multiphasic Personality Inventory (MMPI) * . Hs D Hy Tenderness 0.22 029 Simulation 0.20 0.23 0.20 Distraction 0.29 0.23 Regional 0.19 0.22 Overreaction 0.18 * Study 1, 84 patients: Pearsonian correlation coefficients confirmed by corrected x2 analysis Hs = hypochondriasis. D = depression. Hy = hysteria I. A Set of Five Types of Nonorganic Physical Signs In Low Back Pain II. Can Be Used to Screen Individuals Who Require Detailed Psychological Assessment III. Scoring A. Any individual sign counts as positive for that type B. Three or more types positive= clinically significant A. Tenderness Superficial- skin is tender to light pinch over a wide area of lumbar skin Non-anatomic- deep tenderness over a wide area, not localized to one structure, often extends to thoracic spine, sacrum, or pelvis B. Simulation Test- Give the impression that an examination is being done, when in fact it is not. 1. Axial loading- vertical loading over the standing patient’s skull by the examiner’s hands- may cause neck pain, but shouldn’t cause low back pain. 1. Rotation- turn standing patient to one side by rotating lower extremities (not spine) C. Distraction Tests- reevaluating a positive finding while the patient’s attention is not focused on the test- distraction must be non-painful, non-emotional, and non- surprising 1. Indirect observation- can patient move the body party without pain when not being directly examined? 2. straight leg raise- if positive when examined supine, do “flip test” (sitting SLR)- can be done while testing for Babinski sign while sitting- if no pain in sitting then distraction sign is positive D. Regional Disturbance- widespread vergence from accepted neuro-anatomy 1. Weakness- “cogwheeling” of many muscle groups that cannot be explained neuroanatomically 2. Sensory- “stocking” distribution of sensory changes E. Overreaction 1. disproportionate verbalization, facial expression, muscle tension and tremor, collapsing, sweating. 2. most difficult type of sign to assess because: a. cultural variation b. examiner bias In absence of clear indications for surgery may give sufficient cause not to embark on elaborate and risky preoperative investigations Even with proven and treatable physical lesion multiple nonorganic signs help to identify those patients requiring formal psychosocial assessment before surgery In Waddell’s study (1979) nonorganic signs were equally common among litigants and non-litigants. Waddell G, McCulloch JA, Kummel E, Venner RM: Nonorganic physical sign in low-back pain. Spine, 5(2) 117-125, March/April 1980 Considered by adjuster when red flags in claim, medical reports indicating malingering Considered when employer learns employee working at another job Make sure surveillance on more than one day (avoid “a good day” excuse) Use carefully/follow discovery rules Physicians must rule out sometimes obscure conditions ◦ Tumor, infections ◦ Intractable pain, night pain, rest pain, systemic symptoms ◦ The presence of nonorganic signs, must not prevent the physical assessment and investigation of patients Reduces productivity of industry or military through absenteeism Depletes private and governmental social security, disability, worker’s compensation, and insurance benefits Drains medical system of resources “Fraud that broadly includes malingering costs the insurance industry $150 billion annually, increasing cost of insurance by $1800 per family” Psychiatric Times 2007.